Update letter to the AMS Affinity Groups United

Dear AMS Affinity Groups United,

We are writing to provide an update on The Warren Alpert Medical School of Brown University’s (AMS) responses to your thoughtful joint statement.  We want to affirm that we stand with you and behind our stated commitment to racial justice and health equity.  Furthermore, we commit to protecting and standing in solidarity with our Black, Brown, and Indigenous students and colleagues in strong opposition to the oppressive forces of white supremacy, structural racism, and systemic injustice. This was most recently illustrated by the shooting of Jacob Blake, which we know has had a profound impact on our students and the AMS community.  We strongly condemn this and are saddened and dismayed by this continued police brutality.

Importantly, we also want to acknowledge the incredible work you have done with these paramount initiatives you have articulated.  We do recognize that you may have lost faith in our ability to uphold the principles of AMS. In an effort to regain your trust, as faculty and administration, we want to assure you that we are and will continue to move this and other initiatives forward to combat racism and fight for social justice.

We have already begun work on the important initiatives that you have mentioned (some of which have been ongoing). Given the gravity and totality of the important concerns you have brought forward, we want to respond to all of the points you have raised in your communication with us, as well as suggest other important initiatives, as follows:

1. Fund Anti-Racism Training. We agree that anti-racism training is critical for all faculty, administrators, and staff and will move this forward in partnership with our healthcare affiliates, and by engaging with our clinical faculty.  As such, we commit to developing a process so that all faculty, staff, and administration at AMS will undergo anti-racism training.  For those employed by Brown University, this will be a condition of employment.  For those not employed by Brown University, primarily clinical faculty, this will be expected following initial faculty appointment and with subsequent re-appointments.

2. Publish Disaggregated Demographic Admissions Data. The Administration has begun working with the Office of Admissions team to start analyzing admissions data, and we are working on a process to provide preliminary analyses to students in the immediate term. However, this needs more development, and we welcome the opportunity for student input in moving this forward. For instance, there are 39 disaggregated categories listed through the American Medical College Application Service (AMCAS), plus write-ins, as well as a sizable group of applicants that choose not to answer race and ethnicity questions; we want to ensure that we interpret and report these data with care so as not to mask important findings or further disenfranchise underrepresented groups while also maintaining individual privacy.  As a preliminary step, we have reviewed the information provided to us by student leaders of APAMSA and data, like that from the University of California-San Francisco (diversity.ucsf.edu/URM-definition), to begin the process to create a contemporary definition of Underrepresented in Medicine (URiM) (see the response to 3b, below), as follows:

  1. African American/Black
  2. Asian (Filipino, Hmong, Vietnamese, Cambodian, Laotian, and any other underrepresented Asian groups in medicine)
  3. Hispanic/Latinx
  4. Native American/Alaskan Native
  5. Native Hawaiian/Other Pacific Islander
  6. Two or more races, when one or more are from the preceding racial and ethnical categories in this list

In addition, we will be tracking students identified as first-generation college and of low socioeconomic status.

3. Increase Admission of Black and other URiM Students through the Standard Admission Route. This has been an important initiative at AMS for the last several years that came out of focus groups with URiM students, administration, and alumni in October 2016. We recognize that many URiM students who matriculate to AMS have previously come through Brown’s Program in Liberal Medical Education (PLME) route of admission; for the class that entered in August 2019, 26% of matriculated students identify as URiM with almost similar percentages admitted through the PLME and standard route. Nevertheless, we recognize that the underrepresented population in the United States is continuing to grow and we need to strive to improve in this area. Efforts to further increase the admission of Black and other URiM students through the standard admission route will include specific recruitment visits to Historically Black Colleges and Universities and minority-serving institutions, recruitment events on campus via Minority Association of Pre-Med Students chapters, and attendance at other conferences (e.g., Graduate Horizons). In addition, we will plan to allocate more resources towards scholarship funding to recruit students from diverse backgrounds to AMS.   

  1. Providing a space for URiM applicants to speak specifically with URiM medical students is a great idea and we will organize with the Office of Admissions, ODMA, OSA, and our URiM students.URiM students already reach out to accepted students and we will continue sessions with URiM medical students and accepted URiM applicants at Second Look.
  2. Creating a contemporary definition of URiM is already in progress (see 2, above), but needs to be completed. We are thankful to APAMSA for doing the groundwork with regard to URiM Asian, and we will need continued maintenance to follow “regional” and “state demographic information.” In addition, the definition of URiM will be reviewed and updated regularly.

4. Diversify Faculty and Administration. We recognize that diverse faculty recruitment is mission-critical and admittedly, this has been a significant challenge for us.  As you may know, the lack of faculty diversity at AMS was identified as an area for monitoring during our LCME accreditation review in 2012.  There have been important recruitments of faculty in a number of our basic science and clinical departments, including into leadership roles, but we must do more.  Each clinical department has been charged to develop department-specific Diversity and Inclusion Action Plans, which include efforts for recruitment of a diverse faculty; this metric will be part of performance reviews of each department Chair, and we will update you as to its success.  We will also explore avenues to engage our students with our faculty of color through the ODMA Faculty Association. 

In recognition that housestaff (i.e., residents and fellows) represent an important pipeline of those who are likely to become faculty, there have been important initiatives through the Diversity Visiting Student Program, in which many of our clinical departments are providing funding for URiM students to do visiting rotations at Brown-affiliated residency programs.  This, along with other department-specific initiatives, has led to greater diversity of residents in many of our residency training programs.  Unfortunately, this program was suspended during the COVID-19 pandemic, but we are hopeful that it can be reinitiated in the near term, or that we can create virtual rotation experiences that will attract these students to our training programs.  We will also work with the Graduate Medical Education (GME) programs at Lifespan and Care New England to collect annual data about numbers of URiM students who applied to their program, were interviewed, and matched. 

We have initiated discussions for the development of a Target of Opportunity Program, in conjunction with our clinical chairs and health systems, to provide financial start-up support from the medical school and health systems to assist in the recruitment of URiM faculty.   The hiring of faculty through our departments and health systems must reflect our values, to include training of search committee members and engagement of the Brown University Office of Institutional Equity and Diversity in all searches.  In addition, we need to acknowledge the “diversity tax” in which URiM faculty have been asked to disproportionately take on diversity responsibilities in their departments; more must be done to recognize those faculty and engage others in the department and medical school diversity initiatives and we commit to doing this.

5. Investigate Disparities in Remediation. We have put a number of systems in place to identify and support students having academic difficulty (e.g., the hiring of a full-time learning specialist, a robust tutoring program, and the establishment of the Mary B. Arnold Mentoring Program for personal and professional counseling and development), but more needs to be done to truly investigate disparities in remediation.  We understand there is a concern that URiM students are remediated at a disproportionate rate and we have recently created a de-identified database in which we will examine the data and reasons why URiM students may be overrepresented in regard to exam remediation.  In conjunction with the Committee on Diversity, Inclusive Teaching and Learning, and the Medical Curriculum Committee, which have broad representation by administration, faculty, and students, we will analyze this database and use this analysis to inform decisions around medical school policy and decision-making as it concerns URiM students. 

6. Overhaul Anti-Racist Education. We have and continue to work with our Health Systems Science Course Leaders and Doctoring course leaders on the integration of additional anti-racism curriculum material.  We required Fatal Invention by Dorothy Roberts as a reading for all incoming first-year students, with mandatory small group discussions on this book with preceding faculty involvement and training.  For our rising 2ndyear students, we required How to Be an Antiracist by Ibram X. Kendi, again with mandatory small group discussions and preceding faculty preparation.  We moved the Race and Medicine section in Health System Science forward in the course and added a focus on racism and oppressive policies.

In addition, noting that the Doctoring courses and specifically the small groups have been of great concern, we are modifying the Doctoring course with the following changes:

Faculty Recruitment, Hiring, & Training

The Doctoring Program has benefitted from a dedicated group of small group faculty over the last fifteen years. Recruitment of small group faculty would typically be through informal referrals and word-of-mouth. This limits our ability to recruit a diverse faculty, especially Black, Indigenous, and People of Color (BIPOC) faculty members. For the upcoming academic year, we made changes to our faculty hiring to include the following:

  • A formal application process with specific questions on diversity, the learning environment, as well as discussing race, gender, and sexual orientation.
  • Required interview with a standardized interview form with members of the OME (of which Doctoring is part), the OSA, and the ODMA.
  • Interview questions about diversity and inclusion.

Doctoring Peer Mentor (DPM) Program

The DPM program pairs rising 2nd year students with 1st year Doctoring small groups. Students are nominated by their Doctoring small group faculty and the list of nominations is reviewed by the OME. In the past, selections have been made based on small group participation, clinical skills, and OSCE performance. We realize this process has led to significant underrepresentation of BIPOC students as DPMs due to bias at many levels. This year, we will use the following process to select DPMs:

  • Students will be invited to self-nominate (or nominate a peer) and complete a formal application. We will invite students to provide demographic information to avoid assumptions about demographics.
  • For those who are nominated, feedback will be sought from Doctoring faculty and Mary B. Arnold Mentors.
  • Applications will then be reviewed by members of OME, OSA, and ODMA.
  • We will monitor the DPM selection process and outcomes and continue to refine this process to ensure equitable representation of BIPOC students in the DPM cohort.

Doctoring Small Group Faculty

For the upcoming academic year, a newly created Canvas faculty development portal will house required training for small group faculty. All Doctoring small group faculty will be required to complete:

  • Four anti-racism modules prior to the start of classes (Developing Racial Consciousness, Racism in Medicine, Microaggressions, and Core Anti-racism Texts).
  • One virtual debrief session.
  • Required student summer reading.
  • Additional modules on trauma-informed care, assessment, feedback, and small group facilitation with longitudinal threads of antiracism and ways to minimize bias.

In addition, all Doctoring small group faculty will be observed at least once throughout the semester and provided feedback through the Office of Faculty Professional Development.

Curricular Changes

Rather than focus on incorporating stand-alone sessions that focus on anti-racism, we will weave a longitudinal thread across several aspects of the curriculum. This will include the following:

  • Required summer readings will be incorporated throughout the academic year.
  • Weekly faculty facilitator’s guides will include discussion points from the summer readings as well as a newly collated list of readings and resources.
  • The previous antiracist clinical case presentation session on written documentation will be incorporated into case write-up and oral presentation materials from the start of Year 1.
  • First and second-year students will participate in Bystander Training as part of the Doctoring curriculum using a newly created resource on microaggressions.
  • In the Health Systems Science course, students will be required to achieve at least a 70% on the multiple-choice questions on the IMS exams in order to pass this course. These questions will incorporate everything in the syllabus, including readings.  Furthermore, small group leaders have been trained to give more critical feedback on reflective narratives submitted by students; these reflective narratives will also count towards students’ final grades.

Faculty in the OME have been working with student leaders to revise one of our current core competencies (the Nine Abilities) to reflect AMS's dedication to racial justice. The Ability will be named: Health Equity and Racial Justice with the following competency description: 

The competent graduate practices medicine in a broader context by understanding the many factors that influence health, disease, and disability. The competent graduate recognizes the inextricable role of social and racial justice in medicine to achieve positive health outcomes for all people. The graduate characterizes social issues that impact their patient population and understands different models of action that makes their medical practice more ethical and inclusive. 

The Ability includes five specific, measurable medical education program objectives that students must demonstrate throughout their medical school career. For example, 7.5 Applies social justice theories and resources to frame anti-racist advocacy within the students future practice of medicine. These objectives are mapped to all required courses and clerkships to ensure that they are taught throughout the curriculum. In addition, multi-modal student assessments are integrated into the curriculum map to ensure the measurement of student achievement.  

As part of this ability, we are mapping our current curriculum on health inequity and racial injustice.  We will continue adding to this curriculum in the pre-clerkship, clerkship, and post-clerkship curriculum.  In addition, we will propose a required 4-week clerkship in the third year on Racial Justice and Health Inequity, in which students will be expected to have a deep understanding of topic areas such as critical race theory, intersectionality and the inequities that pervade the United States Healthcare System. 

As noted, we required Fatal Invention by Dorothy Roberts; in addition, we used the anti-racist training developed by the University of Washington as a framework for our incoming students. We are also working with the PLME program to integrate anti-racism training into this vital pipeline program to AMS. 

The OME worked with a student on the Academic Scholars Program (the student was funded by the OME) to identify slides that inappropriately depict race (i.e., using race for example as a risk factor for disease processes). This work will continue as a sub-group of the Committee on Diversity and Inclusive Teaching and Learning.

7. Organize URiM Focus Groups. We agree that focus groups with URiM faculty, administration, and students is very important.  We commit to having these twice annually and will schedule the first in September 2020.  We would like to include URiM housestaff (i.e., residents and fellows) in that group as well.

8. Divest from Safariland. We need to look into this to respond, and can discuss in upcoming forums with students.

9. Protect Student Advocacy. No medical student should fear retribution for speaking up against the medical school, Brown University, or affiliated institutions.  We continue to greatly respect our students who have advocated for themselves, their colleagues, their patients, and the community, and will continue to support our students in these endeavors.  This is an important principle of our learning environment and will continue to be so.  There is already a process for anonymous reporting by students of issues of mistreatment or to identify curricular opportunities that will improve our learning environment, and each report that is received is addressed.  This is already part of the policy for the learning environment and is part of the Medical Student Handbook.  Additionally, we plan to hire a faculty member as a new Assistant Dean for Student Affairs (see below) dedicated to program development and oversight of initiatives related to the learning environment.

10. Publicly recognize this list of demands and your plan to address them and encourage other medical institutions to do the same. This was publicly recognized on the day we received this communication. In addition, we request that you share our responses with affinity group students at other institutions, and encourage them to enlist their medical school leadership to address these important issues.  We will do the same with our colleagues across the United States in leadership roles in medical education.

In addition to our responses to your initial demands, many other important initiatives aimed at combating systemic racism are in process.   These include the following:  

We are organizing a lecture series entitled “Decoding Disparities.”  A committee has been formed to determine who to invite to present in this lecture series, to ensure the process of speaker selection is inclusive and that each lecture topic and presenter will be widely distributed throughout the AMS community.

We will move forward with the following important hires at AMS:

  1. Senior Associate Dean for Diversity, Equity, and Inclusion to work with the offices at AMS, OIED, and the hospital systems, to ensure leadership and oversight of the long-term sustainability of the initiatives listed in this letter amongst other things, while having authority to implement policies and processes. This is a critical hire for the medical school, and we plan to do a national search to recruit for this important position.  Recognizing the urgency of having someone in this position and that a national search will take time, we are pleased to announce that Shontay Delalue, PhD, Vice President for Institutional Equity and Diversity at Brown University, agreed to assume this role on an interim basis so that important initiatives can move forward without delay.
  2. Assistant Dean for Student Affairs to focus on the learning environment and wellness initiatives, and interface with initiatives related to diversity, inclusion, and equity in conjunction with the ODMA and OME.
  3. Assistant Dean for Curriculum on Diversity, Inclusive Teaching and Learning to oversee the anti-racist curriculum at AMS, as well as oversee faculty development.

Additional requests will include funds for faculty development around racism for the Doctoring Program, creation of a Year 3 course on racial justice and equity, a seminar series on race, medicine and health inequities, and programming for the training of clinical faculty and building of pipeline programs.

Thank you again for writing to us.  As you can see, there are many initiatives that will be moving forward during the 2020-2021 academic year, with plans for continued work in subsequent years.  We look forward to continuing to work with you in a collaborative manner to ensure progress on initiatives related to social justice and our commitment to anti-racism.

Sincerely,

Jack A. Elias, MD
Vice President for Health Affairs
Dean of Medicine and Biological Sciences

Allan R. Tunkel, MD, PhD
Senior Associate Dean for Medical Education